Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
HILLSBORO POST ACUTE
HILLSBORO, OH · 99 certified beds · Last Life Safety survey May 8, 2025
CMS Certification Number 365621 · first certified February 1984
Ownership
Operated by PACS GROUP · For profit - Limited Liability company
- New ownershipOwnership changed December 1, 2024 (change of ownership)from LEGACY HILLSBORO OPERATING COMPANY, LLC
Position within OH
14 citations — more than 40% of the 922 certified nursing homes in OH. Compared within OH rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 4 citations; the earlier surveys in the window averaged 5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens January 2027 — about 3 months from now. This facility’s last Life Safety survey was May 2025. Facilities in OH are typically surveyed 20–32 months after the last one (median 26), measured over 889 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 14 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in OH, and nationally. Surveyors differ markedly between states, so the OH figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 14 |
| Median facility in OH | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 26, 2019 | 4 |
| December 15, 2022 | 6 |
| May 8, 2025 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2022-12-15 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2025-05-08 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2025-05-08 |
| K-0226 | Have horizontal exits used in accordance with safety requirements. | 1 | 2019-09-26 |
| K-0281 | Install proper backup exit lighting. | 1 | 2025-05-08 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2022-12-15 |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | 1 | 2022-12-15 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2019-09-26 |
What the citations cover
- Smoke Deficiencies 5
- Egress Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Miscellaneous Deficiencies 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Egress Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Miscellaneous Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 8, 2025 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (May 23, 2025) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (May 23, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (May 23, 2025) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (May 23, 2025) |
December 15, 2022 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Deficient, Provider has date of correction (January 11, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (January 11, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (January 11, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 11, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (January 11, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 11, 2023) |
September 26, 2019 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0226 | Have horizontal exits used in accordance with safety requirements. | Deficient, Provider has date of correction (November 1, 2019) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 1, 2019) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (November 1, 2019) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 1, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.